Current issues of ACP Journal Club are published in Annals of Internal Medicine

Quality Improvement

Review: Telephone and computer communication improves clinical health care process and patient outcome

ACP J Club. 1998 Jan-Feb;128:22. doi:10.7326/ACPJC-1998-128-1-022

Source Citation

Balas EA, Jaffrey F, Kuperman GJ, et al. Electronic communication with patients. Evaluation of distance medicine technology. JAMA. 1997 Jul 9;278:152-9.



To describe and determine the efficacy of distance medicine technologies (electronic communication by computer or telephone) for clinical process and patient care outcomes.

Data sources

Studies were identified in the Columbia Registry of Information and Utilization Management Trials, MEDLINE, HSTAR, PsychLIT, CINAHL, Science Citation Index, and Engineering Index by using the terms telephone and computer.

Study selection

Randomized controlled trials were selected if they evaluated electronic communication (computer or telephone) between persons in separate locations, included a control group that did not have a similar intervention, and measured process or patient care outcomes.

Data extraction

Data, extracted in duplicate, included description and quantification of study quality, patient characteristics, intervention, and health care process or patient outcomes. Interventions were divided into 6 categories: computerized communication, telephone follow-up and counseling, telephone reminders, interactive telephone systems, after-hours telephone access, and telephone screening.

Main results

83 studies were identified, and 80 met quality criteria; 50 of these showed some benefit. Technology that allowed patients to transfer information (modems, networks, and facsimile machines) was evaluated in 7 studies. 4 of these studies included patients with diabetes, and all found improvements in glycemic control; 2 of the other 3 studies did not show improvements. Of 37 studies that evaluated telephone use for follow-up and counseling, 20 showed some improvements: 5 studies involving emergency department visits showed improvements in appointment keeping, patient satisfaction, or patient compliance; 4 studies involving cardiac care showed improvements in behaviors or symptoms; all 3 studies on mammography use showed increased utilization; 2 studies on osteoarthritis showed reduced pain; and 1 study on prevention of tobacco use showed decreased use. Of 23 trials that studied applications of telephone reminders, 14 showed some benefit. Of 9 studies that assessed appointment-keeping rates, 5 found improvements; of 4 that studied immunization rates, 3 found improvements; and of 2 that studied medication compliance, both showed improvements, although weight and diet control were not changed. 1 study on diabetic foot care found fewer serious foot lesions in the intervention group, and 1 study on osteoarthritis found decreased disability and pain but not decreased psychological disability. Of 6 studies that evaluated interactive telephone systems, 5 showed improvements in process (alcohol consumption, adherence to medication, and vaccinations and immunizations).


Distance medicine technologies (electronic communication) can improve clinical process and may improve patient outcomes in some situations.

Sources of funding: National Library of Medicine; National Science Foundation; Arizona State University.

For article reprint: Dr. E.A. Balas, School of Medicine, University of Missouri-Columbia, 324 Clark Hall, Columbia, MO 65211, USA. FAX 573-882-6158.


Many of the studies classified as positive in this systematic summary of the literature showed large and convincing effects (e.g., a 3-fold increase in mammography use and a 24% reduction in smoking). However, the effects in some of the other positive studies were weak (e.g., a before-and-after reduction in hemoglobin Alc levels without a parallel control, or a difference in hemoglobin Alc levels between intervention and control at 6 weeks but not at 12 weeks). Further, all of the benefit cannot be attributed to the telephone communication in some of the positive studies.

A trend toward more hypoglycemia in the intervention group was seen in 1 of the studies of diabetes, and the main effect was more clinic visits—not better glycemic control—in another home monitoring study (1). Perhaps more intense monitoring yields anxious meddling rather than good management.

Regardless, we can expect more uses of new technology to facilitate patient-physician and physician-physician communication. Nurses routinely take off-hour patient calls and use computer protocols to document calls and, in many managed care systems, routinely triage patients. Indeed, such a service is commercially available nationwide in the United States. Some physicians use E-mail to answer patient questions and communicate test results to their patients (2). With telephone links, radiologists, cardiologists, and dermatologists read digital images delivered from remote locations. It is only a matter of time before physicians will be able to see their patients through compressed or slow-scan imaging while they talk to them by conventional or Internet telephone. The more sophisticated technology has not been well studied, and it is hoped that the role of this technology will be determined by evidence rather than by hype.

Clement J. McDonald, MD
Regenstrief Health CenterIndianapolis, Indiana, USA


1. Marrero DG, Kronz KK, Golden MP, et al. Clinical evaluation of computer-assisted self-monitoring of blood glucose system. Diabetes Care. 1989;12:345-50.

2. Voran DA. E-mail: telemedicine tool for the 21st century. Kansas Physician. 1997;3:1.